Porcine Acellular Dermal Matrix for Hernia Repair in Transplant Patients.

PURPOSE: The purpose of this study was to compare clinical outcomes of incisional hernia repair in solid organ transplant patients using non-cross-linked porcine acellular dermal matrix (PADM), human derived acellular dermal matrix (HADM) and synthetic mesh. METHODS: A retrospective review of patients who underwent hernia repair with PADM after pancreas and/or renal transplant at the University of Maryland Medical Center from 2008 to 2012 was conducted. Repair type, postoperative infection, hernia recurrence, mesh removal, and length of follow-up were recorded. Results were compared with our previously published data evaluating HADM and synthetic mesh used in transplant patients between 2000 and 2005. RESULTS: Twenty-seven patients underwent ventral hernia repair with PADM, 34 patients were repaired with HADM and 26 were repaired with synthetic mesh. The rate of wound infection in those repaired with PADM, HADM, and synthetic mesh were 14.8%, 14.7%, and 65.4%, respectively. Rates of recurrence were 13.3%, 23.5%, and 76.9%, respectively. Rate of mesh removal was found to be 7.4%, 11.8%, and 69.2%, respectively. These complication rates were significantly lower in patients who received HADM or PADM compared with patients repaired with synthetic mesh (P < 0.001). There was no statistically significant difference in the outcomes between the groups repaired with HADM or PADM. CONCLUSIONS: The use of PADM for incisional hernia repair after kidney and/or pancreas transplant significantly reduces the incidence of hernia recurrence, wound infection, and need for mesh removal compared to synthetic mesh. No difference in morbidity between HADM and PADM was observed in the study population; however, longer follow-up in the PADM group is warranted.

Utility of indocyanine green fluorescence lymphography in identifying the source of persistent groin lymphorrhea.

SUMMARY: Surgical manipulation of the groin can result in lymphatic injury in a significant number of patients leading to poor wound healing or infectious complications. Surgical repair of lymphatic injury is greatly aided by the precise and prompt intraoperative localization of the injured lymphatic vessels. We assessed and identified lymphatic leaks in 2 cases of surgical wound lymphorrhea occurring after instrumentation of the groin using laser-assisted indocyanine green lymphography paired with isosulfan blue injection. Both cases healed without complication, and no lymphatic leak recurrence was observed during postoperative follow-up. Laser-assisted indocyanine green lymphography is a useful adjunct in the management of lymphatic leaks after surgery of the groin and may have potential for prophylactic evaluation of high-risk groin wounds.

Novel technique for innervated abdominal wall vascularized composite allotransplantation: a separation of components approach.

OBJECTIVE: Applications for Abdominal Wall Vascularized Composite Allotransplantation may expand if a functional graft with decreased immunosuppressive requirements can be designed. We hypothesize that it is anatomically feasible to prepare a functional, innervated, and vascularized abdominal composite graft using a multilayered component separation technique. Including vascularized bone in the graft design may decrease the immunosuppressive requirements by inducing immunologic chimerism. METHODS: Two cadaver torsos were used. Adipocutaneous flaps were elevated from the midaxillary lines, preserving deep inferior epigastric artery perforators. A 2-layered component separation through the external and internal oblique fasciae was carried out, exposing segmental intercostal thoracolumbar nerves. Superiorly directed muscle release over the subcostal margin provided for a 3-rib segment with attached rectus abdominis muscle. The remainder of the full-thickness allograft was harvested with its vasculature. Flap inset into the recipient cadaver abdomen, with osteosynthesis fixation between donor and recipient ribs, was achieved. RESULTS: The harvested grafts had an average size of 845 ± 205 cm(2) with a total procurement time of 110 minutes. On one cadaver, 4 thoracolumbar nerves were isolated bilaterally, while the other cadaver yielded 3 nerves. The nerves were transected with an average length of 5.7 ± 1.2 cm. The graft vasculature was transected with a length of 4.40 ± 0.10 cm. CONCLUSION: Using the principles of component separation technique, we demonstrated a novel approach to harvest and transfer a neurotized osteomyofasciocutaneous abdominal wall allotransplant as a multipedicled, single functional unit.

Emergence of the acute-phase protein hemopexin in jawed vertebrates.

When released from damaged erythrocytes free heme not only provides a source of iron for invading bacteria but also highly toxic due to its ability to catalyze free radical formation. Hemopexin (Hx) binds free heme with very high-affinity and thus protects against heme toxicity, sequesters heme from pathogens, and helps conserve valuable iron. Hx is also an acute-phase serum protein (APP), whose expression is induced by inflammation. To date Hx has been identified as far back in phylogeny as bony fish where it is called warm-temperature acclimation-related 65 kDa protein (WAP65), as serum protein levels are increased at elevated environmental temperatures as well as by infection. During analysis of nurse shark (Ginglymostoma cirratum) plasma we isolated a Ni(2+)-binding serum glycoprotein and characterized it as the APP Hx. We subsequently cloned Hx from nurse shark and another cartilaginous fish species, the little skate Leucoraja erinacea. Functional analysis showed shark Hx, like that of mammals, binds heme but is found at unusually high levels in normal shark serum. As an Hx orthologue could not be found in the genomes of jawless vertebrates or lower deuterostomes it appears to have arisen just prior to the emergence of jawed vertebrates, coincident with the second round of genome-wide duplication and the appearance of tetrameric hemoglobin (Hb).

Construction of a nurse shark (Ginglymostoma cirratum) bacterial artificial chromosome (BAC) library and a preliminary genome survey.

BACKGROUND: Sharks are members of the taxonomic class Chondrichthyes, the oldest living jawed vertebrates. Genomic studies of this group, in comparison to representative species in other vertebrate taxa, will allow us to theorize about the fundamental genetic, developmental, and functional characteristics in the common ancestor of all jawed vertebrates. AIMS: In order to obtain mapping and sequencing data for comparative genomics, we constructed a bacterial artificial chromosome (BAC) library for the nurse shark, Ginglymostoma cirratum. RESULTS: The BAC library consists of 313,344 clones with an average insert size of 144 kb, covering ~4.5 x 1010 bp and thus providing an 11-fold coverage of the haploid genome. BAC end sequence analyses revealed, in addition to LINEs and SINEs commonly found in other animal and plant genomes, two new groups of nurse shark-specific repetitive elements, NSRE1 and NSRE2 that seem to be major components of the nurse shark genome. Screening the library with single-copy or multi-copy gene probes showed 6-28 primary positive clones per probe of which 50-90% were true positives, demonstrating that the BAC library is representative of the different regions of the nurse shark genome. Furthermore, some BAC clones contained multiple genes, making physical mapping feasible. CONCLUSION: We have constructed a deep-coverage, high-quality, large insert, and publicly available BAC library for a cartilaginous fish. It will be very useful to the scientific community interested in shark genomic structure, comparative genomics, and functional studies. We found two new groups of repetitive elements specific to the nurse shark genome, which may contribute to the architecture and evolution of the nurse shark genome.